Doctor To Doctor

When medical professionals work together across borders to make healthcare quality better, many things are shared — expertise, insights, challenges, cultures and even tools. What has it been like for participants in a Singapore-Laos project of the Singapore International Foundation? Here’s a look.

By Kim Lee

Laos faces great challenges in improving the lives of its people, not least lowering its infant and child mortality rates.

Laos faces great challenges in improving the lives of its people, not least lowering its infant and child mortality rates. Photo: Cooperative Orthotic and Prosthetic Enterprise (COPE)

There’s a photograph of a village boy at a local not-for-profit organisation in Laos that is remarkable for the smile it captures. He’s about 10 years old, and the reason for his happiness is a new prosthetic leg. His feelings can be seen as part of a set of survival skills the people of Laos have been honing for years as their country grapples with many trials. The legacy of unexploded ordnance scattered throughout Laos that blew this boy’s leg off is one of them, along with the fallout from so many other challenges of the past 49 years: wars, colonialism, revolution, poverty, malnutrition, poor infrastructure, lack of education and skills….

It could be argued that the people’s resilience and ability to smile in the face of adversity has smoothed the way for help for the country. Governments, non-government organisations, even individuals have stepped in to help get Laos on its feet as it opens up to the 21st century. The Singapore International Foundation (SIF) has been a part of this global wave of aid with its Emergency Obstetrics and Paediatrics Project, a 30-month specialist team programme that seeks to reduce child mortality in the country.

About 50 years ago, 225 children out of every 1000 born in Laos died at birth. With international help, this number has fallen steadily. While the latest child mortality statistics from the United Nations (UN) on Laos shows reduced numbers, it still means that 46 babies out of every 1000 live births don’t make it home; and of every 1000 children who do, 58 do not live to see their fifth birthday.

The SIF’s specialist team project was launched in Laos in 2010 bearing in mind two of the eight Millennium Development Goals outlined by the UN: to lower child mortality and improve maternal health. The project adopted the “train-the-trainer” model to set in place skills and protocols to enable local doctors to skill-up their fraternity.

In October 2012, 12 paediatric surgeons and doctors, gynaecologists, obstetricians, anaesthetists and nurses from KK Women’s and Children’s Hospital (KKH) flew to Vientiane as the Singapore International Volunteers (SIV) to launch the 30-month programme. Their three-day train-the-trainers session there was the fourth training session that ended the obstetrics programme, with two more sessions to go for paediatrics in 2013. Six doctors from obstetrics and paediatrics from KK Hospital run each training session. So far, about 70 Laotian medical professionals brought in by the Laos Ministry of Health from the provinces and the capital have undergone training. The three doctors leading this programme share their insights.

The idea to focus on emergency obstetrics and paediatrics came from an incident during a reconnaissance trip by a small team from KK Hospital in Singapore led by Associate Professor Anette Jacobsen in 2005.

“The first time I went to Vientiane in 2005, we visited three hospitals,” said Prof Jacobsen. “I went with one of our nursing officers and another doctor. We were walking through the emergency department of one of the hospitals when we saw a very sick child being brought in. The nursing officer and I looked at each other and said, ‘Do you think we should do something?’ because we felt they didn’t realise how sick this child was.

Later in the ward, we saw the child perish in front of our eyes, and of course, there were very upset parents, very upset everybody…and it really left an impression on us that perhaps it is not the very high-tech things that need to be done but just learning to recognise who is sick and to get the resuscitation going straightaway. So we talked about not doing surgery but emergency procedures instead. That’s how it started.”

The Singapore International Volunteers brought in a range of life-like mannequins for Laotian medical staff to practice on, such as this ‘child’ to practice heart resuscitation on.

The Singapore team knew little about Laos before the project began. “We didn’t know what the basic infrastructure was like, the problems, what kind of patients they had, their maternal and infant mortality,” said Prof Jacobsen. “Singapore has one of the maternal and child mortality in the world, so it’s a bit like coming from Disneyland to the ordinary ground.”

When the project started, “the participants were very timid,” she remembered. We had to do icebreakers with them (little games with prizes like chocolates and sweets) and it is quite remarkable how, at the end of the day, you can’t get them to stop talking.

“Now they welcome us back like friends, and they have moved into the new Children’s Hospital, which is a big change for them. They are also starting to do the presentations and the training themselves, which is part of our purpose — train the locals to train themselves. We want to equip them to run their own programme and to also go back and assess how they apply what we have shared with them over the years.”

The collaboration has brought several surprises and insights. Prof Jacobsen became a “patient” in one of the earlier obstetric trips, which the participants thought was very funny. She recalled, “Dr Shephali, the lead for obstetrics and gynaecology, told them, ‘This is a very sick patient! Do you know how to do a womb massage?’ And the next thing you know, I was getting this really good lower abdominal massage — they obviously knew how to do it,” she laughed.

Practical work on the medical mannequins certainly encouraged participants to be curious and to interact.

On a more serious note, “The last time I was in the Children’s Hospital, I saw the emergency department. They had set up a triage area — one of the best practices we had shared with them — for a quick overview to see if a child is ill or well. If ill, go to resuscitation; if well, he can wait. They have set up this already and it was very fulfilling to see that. You feel a real sense of gratification.

“We were very happy to see one doctor from obstetrics and gynaecology attending the training twice. We gave him some of the instruments we had brought and he was just thrilled to bits. He said, ‘Now we have more than one set!’ We also gave some obstetric instruments to one of the nurses from Luang Prabang and she too was very appreciative.

“A doctor from a northern province uses our training notes on emergency obstetrics as basic training for hospital staff, and he is following the right principles set out in the training. Though he may not be able to do the training as a team yet, he understands the objectives behind the entire effort.”

Connections and Inspiration

Speaking for the medical team from Singapore, Prof Jacobsen said, “I think we learned how to connect and transmit knowledge in different situations. It is one thing to teach the students in Singapore who are at the top of the school cohort — very quick learners, very IT savvy — and it is very different when one teaches in a different environment and applies what is important in their environment. For example, in Singapore we may say you need to do a CT scan (computerised tomography scan, also known as a CAT scan) and a blood test, and then call so-and-so. Well, if these things are not available, you should still be able to do a basic resuscitation for the patient, so it is good for our doctors to be more grounded.

“For some of our teammates who have not been out of Singapore very much, coming to these places is a massive eye opener. What we see as tourists, as we walk around and see how people live, is very educational for everybody. So, besides training and building team spirit, it is also very good as part of general education for all of us.

“It is also quite inspirational because we bring our trainees along and they all get very inspired to teach and share the knowledge, and to know more about the region as well.

They all say it is so wonderful and they had such a nice time bonding with people that they don’t necessarily work with every day, so it forges a lot of camaraderie in the hospital.

“What really drives us is the hunger for knowledge and the eagerness to work with us that we see from the Laos hospital staff.”

Vientiane’s two-storey Children’s Hospital has an airy, sunny atrium where a long elevated path for wheelchairs that winds its way from ground floor up to the next takes centrestage. Cheerful cartoons decorate the walls leading to the children’s wards tucked at both ends of the building. It is a hospital that Laos and people like Dr Somxay Billamay, the hospital’s Head of Medical Affairs and Allergy Clinic, are proud of, for it is a marker of the country’s progress. It rose from a field at Mittaphab Hospital, where the paved main road to it used to be a broad dirt track.

“We are the main hospital for the capital as well as the referral and training facility for medical students and nurses from other provinces,” said Dr Somxay.

“Before we train others,” the animated man acknowledges, “we have first to be trained ourselves. The Singapore training focuses on emergencies for paediatrics as well as smoother deliveries for mothers.

“Participants are very eager to learn and they enjoy the training. They learned how the ECG (electrocardiogram), normally used in the intensive care unit, could be used in emergencies. They were so excited about the ECG machine that we moved it immediately to the emergency department. We also learned from each other and chatted about some things which you don’t see very much in Singapore — for example, respiratory system problems.

The Children’s Hospital in Vientiane is a proud new addition to the country’s medical facilities, and one of two venues for the SIF’s “train-the-trainer” medical programmes.

“Some of our new doctors were allowed to teach in the project and that is how we learn to train others. Out of the 20 to 25 participants, we managed to identify five trainers for paediatrics. So now, we have a new generation of doctor trainers.

“We learn by observing the way they teach and provide information, and how examples are given — very good, very clear. I learnt how to present, how to speak to people — because sometimes we have the information but we don’t know how to present it in order that participants can understand it properly.

“What is important about the emergency guidelines from KK Hospital is that Singapore is also a tropical Asian country, so it is easier to apply the protocol from here than other countries.”

Getting Better

In contrast to the Children’s Hospital, the Mother & Child Hospital has begun to show its age. Vehicles of all kinds stream past its facade as people arrive by car, motorbike or on feet, and women in everyday local garb walk in with their babies wrapped against them in a sarong. If the narrow road to the hospital was paved, it was hard to tell from the swirl of dust churned by the traffic.

In a conference room where the training is taking place, the Head of Gyneco-obstetric Ward Dr Touy Chanthalangsy quietly observes some 30 participants clustered around different practice stations. Like Dr Somxay, in spite of his regular workload at the Mother & Child Hospital, he’s made time to join the training sessions whenever he can. As with paediatrics, the sessions have a fair amount of practical work with training mannequins and equipment brought in by the Singapore teams.

For realism, mock blood was used in one of the exercises to simulate bleeding, which certainly made training lively and kept the mood buoyant, even as serious issues were discussed. “Maternal mortality is high in Laos,” said Dr Touy. “There is preeclampsia (maternal high-blood pressure), anaemia and infection.

In the countryside, sometimes it is poor nutrition and there is no antenatal care for pregnant women. “Some of our doctors are new staff from the capital, and medical staff from five out of six invited provinces showed up. Sometimes communication is not good in the far provinces so they do not come. Sometimes there is only one doctor in the area so it is difficult to leave for training.

The most important thing is the local staff have good trainers so they learn how to train others.

Training doctors in the finer points of emergency infant resuscitation in obstetrics and gynaecology.

“We learn from textbooks, from neighbouring countries, the Internet and even from sharing with one another — that counts a lot. We shared many things with the Singapore team as we learned new things from them. The guidelines are very useful, especially for staff in the rural clinics and also for community talks.

“Training a trainer takes two years; after that, we will train other staff. It will take a few years to build impact but there will be impact.

We do a survey of the mortality rate for mothers and children every five years to find out.”

On this positive note, he smiles and quietly returns to his duties, leaving with an impression that has been asserting itself over the last three days — that in the hands of their medical professionals, the children of Laos do have a brighter future.

Note: Since 1997, KK Women’s and Children’s Hospital has sent more than 150 staff as volunteers for the Singapore International Foundation’s capacity building projects in Cambodia, India, Laos and Myanmar. To strengthen synergies in collaboration, the SIF and KK Hospital signed a three-year MOU in 2011 to continue their work in enhancing the clinical and medical management skills of women’s and children’s healthcare professionals in the countries mentioned.